27
HEAD-TO-TOE ASSESSMENT
1- Incpect
2- Palpate
3- Percuss
4- Auscultate
-Knock
-Introduce yourself
-Wash hands
-Provide privacy
-Verify client ID, DOB
-Explain what you are doing
(using non-medical language)
Introduction
-What is your name?
-Do you know where you are?
-Do you know what month it is?
-Who is the current U.S. president?
-What are you doing here?
-
A&O X4
= Oriented to Person, Place, Time and Situation
Orientation
-
Pulse: 60-100 bpm
-
Blood Pressure:
120/80 mmHg
-
O2Saturation: 95-100%
-
Temperature: 97.8-99.1°F
-
Respirations:
12-20 breaths per min
“Normal” Vital Signs
Assessingthe strength
of the pulse
note if it’s Labored or unlabored
Effort
note if it’s regular or irregular
Rhythm
Neck, Chest (Lungs) & Heart
- Inspect head/scalp/hair
-Palpate head/scalp/hair
-Raise eyebrows
-Smile
-Frown
-Show teeth
-Puff out cheeks
-Tightly close eyes
-Inspect
-Check for symmetry
-To assess Cranial Nerve 7, check
....
-Inspects external eye structures
-Inspect color of conjunctiva and sclera
-
PERRLA
• Pupils Equal, Round, Reactive to Light,
& Accommodation
Head & Face
HEAD
VII: Facial
FACE
EYES
-Inspect and palpate
-Palpate carotid pulse
-Check skin turgor (under clavicle)
-Inspect
-Auscultate lung sounds in posterior and lateral chest
• Note any crackles either diminished breath sounds
-Inspect:
• Use of accessory muscles
• AP to transverse diameter
• Sternum confi guration
-Palpate: symmetric expansion
-Auscultate lung sounds anterior and lateral
• Note any crackles or diminished breath sounds
-Auscultate heart sounds (
A
, P
, E
, T
, M
)
with diaphragm and bell
• Note any murmurs, whooshing, bruits,
or muffl ed heart sounds
NECK
POSTERIOR CHEST
ANTERIOR CHEST
HEART
Assess the depth
of the respirations
pulse scale
Pulse is absent
0
Diminished
1+
3+
4+
2+
Normal
Full
Bounding, Strong
Aortic
Pulmonic
Erb’s Point
Tricuspid
Mitral
A
ll
P
eople
E
njoy
T
ime
M
agazine
